Timely admission of patients hospitalized with pneumonia to the appropriate hospital bed has the potential to save lives. However, the use of intensive care unit beds for those who are too well to benefit, or the use of hospital ward beds for patients who are too sick may increase costs without benefiting patients. Over the last two decades, use of "intermediate intensive care" in US hospitals has rapidly expanded as an alternative location of care that attempts to better balance patient need for services with available resources, yet remarkably little is known about the availability of intermediate care (IMC) beds, their organizational features, and their impact on the outcomes of patients with pneumonia.The goal of this proposal is to address this knowledge gap by examining the epidemiology, dominant organizational phenotypes, care practices, and contextual factors and strategies associated with effective IMC implementation for individuals with pneumonia in a large and representative sample of US hospitals. The proposed series of investigations will capitalize on an extremely large dataset containing detailed information about the treatment and outcomes of patients at over 600 US hospitals. Our study has three aims: Aim 1. We will empirically determine and categorize the subtypes of intermediate care use by linking data from hospitalized patients with pneumonia receiving care in IMCs with surveys of leaders within the same hospitals that capture the environment, staffing, and organizational features of those IMCs. Aim 2. We will determine the effect of intermediate care unit subtype on patient outcomes using statistical models for causal inference. The analyses in this aim will also be instrumental in defining a group of high-performing hospitals with the dominant sub-type of IMC that deliver effective IMC to patients with pneumonia. Aim 3. We will define optimal practices at sites with the best outcomes associated with intermediate care by performing site visits to the top-, mid-, and low-performing hospitals with the dominant subtype of IMC. Through site tours, interviews of key informants, observations, and document collection, we will collect data on each institution's resources, review intermediate care policies and protocols to identify the contextual factors and strategies associated with effective IMC delivery.By transitioning away from whether IMCs work toward how and under what circumstances they work best, our project will be the first rigorous examination of the factors that define effective IMCs, as well as effective care for patients hospitalized with pneumonia. Ultimately, these results will provide clinicians, hospital administrators and policy makers with immediate, actionable data about how to use IMCs most effectively and efficiently, leading to improved survival for patients with pneumonia.